4 Table of Contents Acknowledgements Executive Summary Part 1: Introduction and Background Information What We Know, What We Don t Know and What We Need to Know About LGBTQ Research Issues: Who Counts, What Counts, How to Count History - The Sexologists The Diagnostic and Statistical Manual of Mental Disorders Gender Identity Disorder (GID) Etiology: The Choice Debate...32 The Many Forms of Stigma...35 Minority Stress Majority Rules - Anti-LGBTQ Initiatives Coming Out / Staying In HIV and AIDS Alcohol and Other Drugs (AOD) Domestic Violence...47 Suicide...52 Resiliency Mental Health Services: The Good, the Bad, and the Harmful...54 First Do No Harm Lack of Training Seeking Cultural Competence Intersecting Identities Lesbians...64 Gay Men Bisexual Individuals Transgender Individuals People of Color Who Are LGBTQ Asian American, Native Hawaiians and Pacific Islanders Black/African American/African Descent...87 Latino/Hispanic/Mexican American/Chicano Native American Two-Spirit...95 Couples Parents, Children and Families Youth Older Adults Part 2: Research Methodology Community Engagement Information Gathering: A Multi Method Approach Strategic Planning Workgroup Community Dialogue Meetings Advisory Groups Community and Provider Surveys Data Analysis and Preparation of Findings Study Limitations

12 Special Thank You We are grateful to Rachel Guerrero, members of the former Office of Multicultural Services (OMS), and all others who were involved in the creation of the California Reducing Disparities Project (CRDP) as well as recognizing that LGBTQ communities need to be included when addressing mental health disparities. We are extremely appreciative of all the support we have received from both the staff of the former OMS and staff from the Office of Health Equity (OHE), including Autumn Valerio, Claire Sallee, Kimberly Knifong and Shayn Anderson. We would particularly like to thank Marina Augusto for her leadership at the former OMS and during the transition to the OHE and California Department of Public Health. We would like to thank the California LGBT Health and Human Services Network for their support in launching this project. We would like to gratefully acknowledge the California MHSA Multicultural Coalition, the African American, Asian and Pacific Islander, Latino, and Native American Strategic Planning Workgroups for their support and contributions to the success of this project. We appreciate and value the help we received from interns at Equality California Institute: Melissa Estrada, Annie Kors, Cecilia Mills and Nayeli Pelayo. Finally, there is no way to truly express the gratitude we feel toward all the community members who supported this project in so many ways, including hosting community meetings, providing publicity, and helping with outreach efforts. Although already acknowledged as contributors to the report, we want to thank again all the subject-matter experts who so graciously gave of their time and added to the richness of the report. Most importantly, we want to thank every Community Dialogue and survey participant for their time and their voices. As this report will go on to state, we are multiple communities who identify ourselves in many different ways. We value, recognize and are indebted to all those who were willing to come together in order to help reduce disparities and increase mental wellness for all sexual orientations, gender identities and gender expressions in California. 10

13 Executive Summary In collaboration with Equality California Institute and Mental Health America of Northern California, the Strategic Planning Workgroup (SPW) of the Lesbian, Gay, Bisexual, Transgender, Queer and Questioning (LGBTQ) Reducing Disparities Project was charged by the former California Department of Mental Health (DMH) to seek community-defined solutions for reducing LGBTQ mental health disparities across the state of California. The project is funded through the Prevention and Early Intervention (PEI) component of the Mental Health Services Act (MHSA). The LGBTQ Reducing Disparities Project was an enormous undertaking. Like the other underserved groups African American, Asian and Pacific Islander, Latino, and Native American targeted for assessment in the larger California Reducing Disparities Project, LGBTQ people exist in every geographic and economic range. Unlike the other groups, however, LBGTQ people are also found in every racial and ethnic group. Furthermore, each population represented by the acronym LGBTQ has its own needs as well as its own issues of diversity. Age, gender, sex assigned at birth, socioeconomic status, education, religious upbringing, and ethnic and racial backgrounds all play a role in how an individual experiences their sexual orientation and gender identity. For this reason, this report includes significant discussion of the literature that provides a necessary background to inform mental health professionals understanding of LGBTQ lives. Methodology In accessing California s widespread and diverse population, the methodology used by the LGBTQ Reducing Disparities Project involved extensive engagement of community members and subject matter experts from across the state through Advisory Groups and a Strategic Planning Workgroup (SPW). Because of the wide diversity of the target population, and the difficulties inherent in achieving access to various subgroups within it, the project utilized a multi-method approach. Community Dialogue meetings were held in 12 communities, drawing over 400 people. The information gathered in these live sessions, along with extensive Advisory Group and SPW input, guided the development of the online LGBTQ Reducing Disparities Community Survey, which was the primary research tool used to gather quantitative information There is a myth that LGBTQ is one community, once we get beyond the gay we still need to support one another we are more than just labels. We are individuals. Desert Valley Community Dialogue participant We injure ourselves by saying we are a community, we are many communities. Desert Valley Community Dialogue participant 11

14 about LGBTQ-identified Californians. This method was chosen to complement the in-person outreach of the Community Dialogue meetings, as well as the continual input from Advisory Group and SPW members. The online survey provided an avenue for reaching populations traditionally hidden or invisible. Over 3,000 California residents (N = 3,023) who identify somewhere on the LGBTQ spectrum responded to the Community Survey (CS), surpassing the initial goal of 2,500 respondents. One of the major concerns raised by using an online process as a survey tool is one of access. Those who may be facing the most severe disparities may also not have access to, or be reached by, a survey tool that is totally Internet-based. Many agencies and programs serving hardto-reach LGBTQ populations promoted the CS and allowed clients access to computers so their voices could be heard. Every recommendation made in this report should be viewed with the diversity of the LGBTQ communities in mind. Findings Overall, approximately three quarters (77%) of CS respondents indicated they had sought mental health services of some kind. Trans Spectrum individuals reported seeking services at an even higher rate (85%). Community Survey Findings This report s findings illuminate the diversity of the target population, and the difficulties its members experience with respect to accessing and receiving appropriate mental health care. For example, CS respondents were asked how much they agreed with the following statement: I have experienced emotional difficulties such as stress, anxiety or depression which were directly related to my sexual orientation or gender identity/expression. Over 75% somewhat or strongly agreed that they had. The Trans Spectrum group reported the highest rate of agreement (89%). Queer-identified individuals, Native Americans, and youth also reported higher rates than other subgroups. Even though older adults had the lowest rate, almost two-thirds of the group still somewhat or strongly agreed. Other important findings include: Overall, approximately three quarters (77%) of CS respondents indicated they had sought mental health services of some kind. Trans Spectrum individuals reported seeking services at an even higher rate (85%). CS participants were asked to indicate which mental health services they needed or wanted, but did not receive. Individual counseling/therapy, couples or family counseling, peer support 12

15 groups and non-western medical intervention were ranked by all subgroups as 4 of the top 6 services they reported seeking, but not receiving. All subgroups (except youth) also ranked group counseling/therapy among the top six services they sought, but did not receive. For the general CS sample (all subgroups combined), Western medical intervention was ranked sixth of those services sought, but not received. Queer, youth, older adult, and people of color (POC) subgroups all indicated seeking but not receiving ethnic/community-specific services. Notably, Trans Spectrum respondents ranked counseling/therapy or other services directly related to a gender transition and Latino respondents ranked suicide prevention hotline as the number six service they sought but did not receive. CS respondents were provided a list of problem areas that was developed from Community Dialogue feedback and Advisory Group discussions. CS respondents were asked to indicate whether each area listed was a problem for them in the past 5 years. Concerns most frequently reported as a severe problem by all or most subgroups were: 1. Did not know how to help me with my sexual orientation concerns all subgroups. 2. Did not know how to help me with my gender identity/ expression concerns all subgroups. 3. My sexual orientation or gender identity/expression became the focus of my mental health treatment, but that was not why I sought care all subgroups. 4. Made negative comments about my sexual orientation most subgroups. 5. Did not know how to help same-sex couples most subgroups. 6. Did not know how to help mixed-orientation couples (e.g., one partner straight/one partner gay or one partner lesbian/one partner bisexual) most subgroups. It should be noted that Made negative comments about my gender identity/expression was also one of the most frequently reported severe problems by Trans Spectrum, Queer, youth, Asian Americans, Native Hawaiians & Pacific Islanders (AA & NHPI), Black, Latino and urban subgroup respondents. Trans Spectrum 13

16 Respondents who reported having only Medi-Cal had more difficulty accessing the services when they needed and wanted them than those who reported having private insurance, Medicare, another type of government insurance (e.g. VA, Tri-Care, Indian Health) and/or a combination of the above. Community Survey findings respondents were 4 times as likely (P <.001) to have this problem than non-trans Spectrum respondents. In addition, they were 5 times more likely to have mental health providers who did not know how to help me with my gender identity/expression concerns. CS participants were asked how satisfied they were, in general, with the mental health service(s) they had received in the past 5 years. Only 40% of LGBTQ respondents stated they were very satisfied, although satisfaction rates differed among subgroups. Older adults reported the highest rate (60%) and youth the lowest (23%) for very satisfied. Trans Spectrum (31%), Bisexual (32%), Queer (25%), AA & NHPI (24%), Latino (36%), Native American (29%) and rural (35%) subgroups all had even lower rates of very satisfied than the overall sample. Respondents who reported having only Medi-Cal had more difficulty accessing the services when they needed and wanted them than those who reported having private insurance, Medicare, another type of government insurance (e.g. VA, Tri-Care, Indian Health) and/or a combination of the above. Only 45% of Medi-Cal respondents were able to access couples or family counseling compared to 69% of those with private insurance. Only 40% were able to access Western medical interventions compared to 75% with private insurance and 84% with Medicare. Finally, only 37% were able to access peer support groups compared to 77% with private insurance, 71% with other governmental insurance, 91% with Medicare and 81% of those with some combination of the above. Researchers also conducted the LGBTQ Reducing Disparities Provider Survey (PS) to complement the Community Survey. The PS allowed the Research Advisory Group to develop questions specifically intended to assess barriers providers may face in providing culturally appropriate, sensitive and competent care to membes of LGBTQ communities. In addition, the PS included questions to address the intersection of being both LGBTQ and a service provider. The PS was made available to mental, behavioral and physical health care professionals, educators, administrators, office staff, support staff, and anyone who comes in contact with clients, patients, students and/or family members, whether or not they provide services specifically for LGBTQ individuals. Over 1,200 (N = 1,247) providers working 14

17 or volunteering in California completed the PS, including over 350 providers who also identified as LGBTQ. Using an adaptation of the Gay Affirmative Practice (GAP) Scale developed by Catherine Crisp (2006), researchers were able to assess the extent to which the provider respondents engage in principles consistent with gay affirmative practice. The most significant finding here is that training matters; the higher the number of trainings specific to LGBTQ issues, the higher the GAP scores. In general, LGBTQ providers took more trainings than heterosexual providers, but sexual orientation does not predict greater competence. Regardless of sexual orientation, increased numbers of trainings attended resulted in more affirming providers. Recommendations Two central concepts have come out of this research. LGBTQ people are being harmed daily by minority stressors such as stigma, discrimination, and lack of legal protection, prior to entering mental health services. Further, there is a profound lack of cultural competence, knowledge and sensitivity among providers who are expected to work with them once they access services. Among the recommendations contained in this report, some of the most important are: Demographic information should be collected for LGBTQ people across the life span, and across all demographic variations (race, ethnicity, age, geography) at the State and County levels. Standardization of sexual orientation and gender identity measures should be developed for demographic data collection and reporting at the State and County levels. Race, ethnicity, culture and age should be considered and the measures differentiated accordingly. Statewide workforce training and technical assistance should be required in order to increase culturally competent mental, behavioral and physical health services, including outreach and engagement, for all LGBTQ populations across the lifespan, racial and ethnic diversity, and geographic locations. Training of service providers in public mental/behavioral and physical health systems should focus on the distinctiveness of each sector of the LGBTQ community lesbians, gay men, bisexual, transgender, queer and questioning within an Regardless of sexual orientation, increased numbers of trainings attended resulted in more affirming providers. Provider Survey findings Demographic information should be collected for LGBTQ people across the life span, and across all demographic variations (race, ethnicity, age, geography) at the State and County levels. First, Do No Harm: Recommendations Statewide workforce training and technical assistance should be required in order to increase culturally competent mental, behavioral and physical health services. First, Do No Harm: Recommendations 15

18 All locations where State or County funded mental/ behavioral and physical health care services are offered should be required to be safe, welcoming and affirming of LGBTQ individuals and families across all races, ethnicities, cultures, and across the lifespan. First, Do No Harm: Recommendations overarching approach to mental health throughout the lifespan for the racial, ethnic and cultural diversity of LGBTQ communities. Cultural competency training, therefore, cannot only be a general training on LGBTQ as a whole, but also needs to include separate, subgroup-specific training sessions (e.g., older adult, youth, bisexual, transgender, Black, Latino, etc.). Development and implementation of effective anti-bullying and anti-harassment programs should be mandated for all California public schools at all age and grade levels and should include language addressing sexual orientation, perceived sexual orientation, gender, gender identity and gender expression issues. In addition, implementation of evidence-based, evaluated interventions that specifically address physical bullying and social bullying should be mandated for all California public schools at all age and grade levels. All locations where State or County funded mental/behavioral and physical health care services are offered should be required to be safe, welcoming and affirming of LGBTQ individuals and families across all races, ethnicities, cultures, and across the lifespan. State and County mental/behavioral health and physical health care departments should create an environment of safety and affirmation for their LGBTQ employees. Conclusion The need for culturally competent mental health services is great, but greater still is the need to eliminate the multiple harms that contribute to negative mental health throughout LGBTQ communities. This report represents a snapshot in time of certain LGBTQ people living in California. Not everyone that could or should be included is in the picture. In many ways, LGBTQ cultural competency work is still in its infancy, with growth and changes occurring rapidly. This report, therefore, cannot and should not be the final word in reducing disparities for LGBTQ Californians. The work begun by the LGBTQ SPW, including community engagement, advocacy, data collection, and community-based recommendations, needs to be continued, and the LGBTQ Reducing Disparities Project should remain funded beyond the dissemination of this report. Nevertheless, the authors of this report are extremely proud of the accomplishment of the long list of contributors and volunteers who worked on this project and made this landmark 16

19 document possible, and they hope the entirety of the information it contains will educate and inspire its readers to continue working to eliminate the mental health disparities and harm LGBTQ populations continue to experience. 17

20 Part 1: Introduction and Background Information In response to the call for national action to reduce mental health disparities and seek solutions for historically underserved communities in California, the Department of Mental Health (DMH), in partnership with Mental Health Services Oversight and Accountability Commission (MHSOAC), and in coordination with California Mental Health Directors Association (CMHDA) and the California Mental Health Planning Council, have called for a key statewide policy initiative as a means to improve access, quality of care, and increase positive outcomes for racial, ethnic and cultural communities. (California Department of Mental Health [DMH], 2010, p. 1) In collaboration with Equality California Institute and Mental Health America of Northern California, the Strategic Planning Workgroup (SPW) of the Lesbian, Gay, Bisexual, Transgender, Queer and Questioning (LGBTQ) Reducing Disparities Project was charged by the former California Department of Mental Health (DMH) to seek communitydefined solutions for reducing LGBTQ mental health disparities. The SPW was asked to move beyond defining disparities and seek solutions which include culturally appropriate strategies to improve access, services, outcomes and quality of care (DMH, 2010, p. 1). There is no doubt that LGBTQ communities are unserved, underserved and inappropriately served within the mental health care system, and the charge from the former DMH is warranted and valid. LGBTQ individuals seek mental health care at rates far beyond their heterosexual and/or gender conforming counterparts and deserve to be treated in an appropriate and culturally competent manner. However, simply seeking to correct disparities for LGBTQ individuals within the mental health care system is akin to treating a symptom without first examining the disease. The LGBTQ Reducing Disparities Project is funded through the Prevention and Early Intervention (PEI) component of the Mental Health Services Act (MHSA). First and foremost, therefore, prevention should be the operative term when discussing LGBTQ disparities and first, do no harm should be the credo. LGBTQ individuals are being harmed on a daily, weekly, monthly, yearly, and sometimes lifetime basis due to stigma, discrimination, prejudice, rejection and legal inequality. 18

21 They represent essentially invisible populations whose existence is not accurately documented and rarely acknowledged in any form of official data gathering. For LGBTQ individuals who are also members of other disparity groups, such as Asian American, Black/African American, Latino, Native American and Native Hawaiian/Pacific Islander, the harm they experience is compounded on multiple levels. To truly prevent mental health disparities and promote mental wellness the California Department of Public Health, the Office of Health Equity, the Department of Health Care Services, MHSOAC, CMHDA, the Californian Mental Health Planning Council, California legislators, school administrators, and service providers of all types must be committed to preventing the harm LGBTQ individuals are exposed to by society-at-large. The need for culturally competent mental health services is great, but greater still is the need to eliminate the multiple harms that contribute to negative mental health throughout LGBTQ communities. Unraveling the Rainbow Although often referred to as such, LGBTQ is not a homogeneous, monolithic entity. Each population represented by the acronym has its own needs as well as its own issues of diversity. Age, gender, sex assigned at birth, socioeconomic status, education, differences in abilities, religious upbringing, and ethnic and racial backgrounds all play a role in how an individual experiences their sexual orientation or gender identity (Wierzalis, Barret, Pope, & Rankins, 2006). LGBTQ is also not a single community but rather represents many diverse communities and populations. The New Oxford American Dictionary (2001) defines community as a group of people having a religion, race, profession, or other particular characteristic in common (p. 347). What LGBTQ individuals have in common is they are seen as living outside the norm of expected heterosexual and assigned gender behavior, and therefore may and do experience stigma, discrimination and oppression from government, health systems, school systems, religious institutions, employers, family members and society-at-large. The acronym LGBTQ is used in this report for the sake of brevity and as an attempt to utilize somewhat commonly understood language. This usage, however, comes with the caveat that the LGBTQ acronym does not represent all individuals or populations whose sexual orientation, gender identity or gender expression is seen as outside society s expected There is a myth that LGBTQ is one community, once we get beyond the gay we still need to support one another we are more than just labels. We are individuals. Desert Valley Community Dialogue participant We injure ourselves by saying we are a community, we are many communities. Desert Valley Community Dialogue participant 19

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